Infant and Young Child Feeding in Emergencies

Anne Merewood PhD MPH IBCLC

Director, Center for Health Equity, Education and Research (CHEER) at Boston

University School of Medicine

Associate Professor of Pediatrics, Boston University School of Medicine

Associate Professor of Community Health Sciences, BU School of Public Health

Today’s training webinar

• Introduction to CHEER

• Breastfeeding and formula feeding

• What’s going on in Athens and Greece?

• Overview of IFE (Infant Feeding in Emergencies)

• Your questions/feedback about infant feeding

• Supporting mothers in their feeding practices

• Brainstorming session on collaboration with CHEER and next steps

Hello from CHEER at Boston Medical Center/Boston University

CHEER’s Background

• The Breastfeeding Center (1997) - originally a clinical service,

became a research-based Center in 2006

• Became CHEER (Center for Health Equity, Education, and

Research) in 2016 with a focus on intervention and evaluation

• We work across the USA with a particular focus on Mississippi

and ‘Indian county’ (Midwest, Alaska, Montana)

• CHEER is a national member of the US Breastfeeding Committee

CHEER Team

Populations CHEER works with in the US

• African American populations in the south

• American Indian and Alaska Natives

CHEER’s areas of practice…

• Breastfeeding; infant feeding• Baby-Friendly Hospital Initiative• Training, assessment, evaluation• Public health approach – working to change things

‘upstream’ before they create problems downstream• We have just created CHEERing – an Athens-based NGO

which will work in partnership with CHEER

Breastfeeding benefits for infants include…• Lower risk of:

• Ear infections (otitis media)• Gastroenteritis• Severe lower respiratory tract infections• Atopic dermatitis• Asthma• Obesity• Type 1 and 2 diabetes• Childhood leukemia• Sudden infant death syndrome (SIDS)• Necrotizing enterocolitis(Agency for Healthcare Research and Quality U.S. Department of Health and Human Services)

The WHO estimates that increasing breastfeeding to near universal levels would..………..

• Save >800 000 lives every year, most of them children under 6 months

• Prevent ½ of all diarrheal diseases and 1/3 of all respiratory infections in children in low- and middle-income countries

• Prevent an additional 20,000 deaths from breast cancer in women

More benefits for women

• Self esteem

• Ability to control something – no need for any outside help

• Empowering and fulfilling

• It’s FREE! All the money spent on formula could be spent on those darn diapers!!

Breastfeeding recommendations: WHO

• Exclusive breastfeeding for 6 months•Continue to 2 years or beyond• Start solids at 6 months

Do breastfed babies need anything else?

• As long as babies have access to the breast, they do not need water, formula, or any other fluids before 6 months

• Before 6 months, infants may need vitamin D • At 6 m they need foods to supply iron, calories (~9m),

vitamins, minerals, etc

What if mother doesn’t make enough milk?

• Breastfeeding is supply and demand. This is the most important fact to remember

• If mothers are not breastfeeding their infants, then they will not make milk

• If a mother has twins, she can make enough milk for 2 babies• Unless circumstances are extreme (starvation), women can make

enough milk

What if babies get sick?

• For ‘a cold’ or any other ‘normal’ illness, breastfeeding is the best defense – antibodies pass through mother’s milk to baby

• Obviously, a sick child needs to be seen by a health care professional when possible

• Few contraindications – some medications, HIV+ (sometimes); ‘galactosemia’ in the infant

What about emergency conditions?

• In suboptimal situations, breastfeeding becomes a matter of life and death

• Antibiotics, vaccinations, electricity, literacy, etc. mean that in ‘developed’ nations formula feeding, while not great, is usually safe

• In emergencies, formula feeding is not safe

Breastfeeding vs formula feeding in a crisis

• To make, store, and feed formula safely, you need:• Infant formula…enough, and age appropriate (not animal milk)• Reliable source of clean water• Place to boil/sterilize water• Sterile feeding bottles• Refrigeration• Bottles refrigerated, not re-used• Ability to read the directions (concentration of powder to water; frequency

and volume of feeds, etc)

Breastfeeding….needs no

• Sterilization

• Refrigeration

• Bottles

• Money

• Literacy

• Special diet…

Formula marketing

• Since its invention in the late 1800s, formula has been aggressively and unethically marketed, most recently in developing nations

Formula marketing in developing nations

• Nestle – deceptive strategy • When women give formula in the

early days, their milk dries up and they do not make a full supply

• This is why WHO’s Code of Marketing and “Baby-Friendly Hospital Initiative” require that hospitals do not give out free formula to mothers in the hospital

What do we know about Athens and Greece?

• Among Greek women (2017): Initiation around 94%

• Exclusive breastfeeding at 1 month – 40%

• Exclusive at 6 months <1%

• Cesarean rate around 60%

What about refugees here?

• CHEER did a study to assess infant feeding status among infants of refugee women in greater Athens

• We analysed deidentified infant feeding information supplied by AMURTEL, collected via client intake form over 6 months in 2017/18

Breastfeeding among refugees in Athens

• 318 mother-infant pairs from 30 nations; most common nationalities Afghani (37%) and Syrian (24%)

• 40% of births by Caesarean section • 92% of women initiated breastfeeding• Median duration of exclusive breastfeeding = 4 weeks• The most common reasons for starting formula were

• ‘Not enough breastmilk’ (31%) and• ‘Formula given by a health professional’ (19%)

Breastfeeding among refugees in Athens

• Not breastfeeding within the first hour associated with shortened duration of any (AHR 6.81; 95% CI 1.81-25.62) and exclusive breastfeeding (AHR 2.1; 95% CI 1.24-3.55).

• Cesarean birth associated with shorter duration of exclusive breastfeeding (AHR 2.01; 95%CI 1.24-3.55).

Conclusion: WHO infant feeding guidelines are not being met…..

Child growth in 4 North Greece camps

• Study of 177 children under 5 , in four N Greek refugee camps, 2016

• 17% were stunted (low height for age) – this included 3 children under 1 year

• Only 2% were severely malnourished

• Stunting suggests chronic malnutrition

• Authors suggested micronutrition supplements

Cross sectional growth assessment of children in 4 refugee camps in Northern Greece, Royal Society for Public Health 2018

IFE guidelines in Attika area camps

• The Emergency Nutrition Network and UNICEF created the Infant and Young Child Feeding in Emergencies Operational Guidelines (OG-IFE) to guide organizers/administrators/volunteers working in camps/other emergency situations

• CHEER assessed implementation of IFE Operational Guidelines by reviewing UNHCR’s Site Profiles for Greek Refugee camps (May 2018) and by 1 on 1 interviews with the field coordinators responsible for day-to-day camp operation in the 6 Attika-area camps

IFE guidelines in Attika camps

• 6000+ refugees in 6 Attika camps• UNHCR’s Site Profiles documents

mother-infant safe spaces at 3, but field coordinators report only 1

• IFE guidelines recommend policies and training, but no field coordinators were aware of any IFE-related policies or any training for clinicians, staff, or volunteers

So what are the IFYCE guidelines?

• Created by UNICEF ++ as part of the WHO/UNICEF global strategy on infant and young child feeding

• Apply to emergency preparedness, response and recovery to minimize infant and young child morbidity and mortality

What do the guidelines say?

• Basically – breastfeed exclusively for 6 months

• Don’t substitute

• Begin appropriate solids at 6 months

• Children 6m to 2 years may need vitamin and mineral substitutes

• Infant formula should be avoided and not distributed for free

Breastfeeding – who’s done it?

• Who’s given birth? – Male obstetricians?

• Who’s had cardiac surgery? – All heart surgeons?

• You don’t have to have breastfed to help!!

• At its core, breastfeeding is simple

• Unfortunately it’s not always easy

• But anyone can learn the rules

The Baby-Friendly Hospital Initiative

• Created in 1991 by WHO• Aimed at hospitals• Outlines standards of care

for new moms and babies• 4 in Greece

Ten Steps to Successful Breastfeeding

1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes1b. Have a written infant feeding policy that is routinely communicated to staff and parents.1c. Establish ongoing monitoring and data-management systems.2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.3. Discuss the importance and management of breastfeeding with pregnant women and their families.4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.8. Support mothers to recognize and respond to their infants’ cues for feeding.9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.

Greece has 4 Baby-Friendly hospitals

• Attikon

• Elena

• Areteio

• Preveza

Basics of supporting breastfeeding women

• Get to them in pregnancy

• Prepare them for what to expect in hospital

• Reassure them that breastfeeding is best and they can do it!

• Ask them what questions or concerns they have about breastfeeding

In pregnancy and at time of birth

• There is no special preparation physically for breastfeeding

• Discuss feeding choice using open ended questions –• Not “are you going to breastfeed or formula feed” but

• “What are your thoughts on how you’ll feed the baby…?”

• Or “What have you heard about breastfeeding?”

• Full milk supply can take 3 days to come in

• Sometimes new mothers think they have no milk, but colostrum “liquid gold” the 1st milk is highly nutritious and primes the gut

Breastfeeding basics

• Remember it’s all supply and demand• Moms and babies need to be together and infants need unrestricted

access to the breast• Infants need to be properly “latched on” to get enough milk – if milk

isn’t transferred, it hurts, and milk supply will suffer• Infant weight should be monitored and charted on growth charts• If there are problems, the baby should be seeing a clinician

Growth charts –our guidance to how a baby is developing

Red dots show baby’s weight for length over time

What is happening to this baby?

In “successful” breastfeeding

• Infant should pee and poop frequently (2 poops/day 2; 3 day 3; 4 day 4). Later (6 weeks+) infants poop much less

• Infant should eat 8-12 times in 24 hours

• Infant should be back to birthweight within 7-10 days of birth

• Pee should be clear or yellow (orange crystals = dehydration)

• Breastfed baby poop should be bright yellow and like yogurt or mustard (formula fed poop is green/brown)

• Mother should not be in pain when breastfeeding

High risk babies• Infants born before 38 weeks gestation

• May be small, sleepy, difficult to feed

• Premature infants who stayed in intensive care

• Infants with poor intrauterine growth (small for gestational age)

• Infants with physical issues (cleft lip, severe tongue tie)

• Infants whose mothers have had no prenatal care and those not seen regularly by a pediatrician/doctor

Important to note danger signs and refer

• Orange crystals in diaper (uric acid crystals/dehydration)

• Skinny older baby

• Mother has fever; pain in breast (could be mastitis)

• Baby is lethargic and does not eat

• Yellow baby (jaundice?)

• Baby is “good” or “sleepy”

• There’s a sudden change in behavior (infant stops eating, is extremely irritable, etc)

• Baby not on growth curve

Why does no one ever have enough milk?

• Almost all women can make enough milk….• As long as they feed a lot from the start• “On demand” or “cue based” feeding is important• Women lose confidence if health care professionals tell them

they need to supplement• You cannot see breastmilk like you can see formula in a

bottle

Why do so many women formula feed…..

……….when in their culture, everyone breastfeeds?

• Immigrants may copy what they see around them

• Where breastfeeding is the ‘norm’ women may not even think about it being a healthy or not healthy possibility

• Stress or depression related – maybe on medications, maybe think they cannot make enough milk

• Time commitment if they have other children and no support

• We should really ask them………….

Relactation and supplementing

• Relactation is possible but lots of BUTS• Infant sucking at the breast will bring more milk…• Mother should feed baby at breast all the time and hand express

• But – it depends on how old the baby is (younger=better)• But – a baby who was depending on formula must be carefully

monitored, mother cannot just go back to breastfeeding• But – if the milk supply has been reduced, it may never recover• Be very careful about recommending relactation

Safer formula tips

• Clean environment• Sterilize bottles, especially for

young babies • If using powdered formula,

measure carefully (WHO does not recommend powdered formula)

• Water should be boiled

Safer formula tips

• Formula should be refrigerated (24 hours max in fridge)

• Formula should be thrown out after 1 hour at room temperature

• Formula should not be re-used, but thrown out

• WHO recommends cups not bottles

• Don’t prop the baby with a bottle – the baby can choke

Weaning

• After 6 months infants start to need solid foods

• First foods are culturally dependent

• Should be nutritionally appropriate (not sugary, highly refined)

• Animal milk is not recommended before 12 months

Complementary feeding

• Infants age 6 months to 24 months

• Guiding Principles – WHO recommendation

• Nutritional requirements

• Adequate and safe complementary foods

Principles for complementary feeding• Good hygiene and proper food handling

• Start at 6 months of age – small amounts of food

• Gradually increase amounts, food consistency and variety – colours!

• Responsive feeding

IMPORTANT

• Feed a variety of foods

• Ensure nutrient and energy needs are met

• Ill infants – increase fluid intake and encourage child to eat easy to eat foods

Links to Resources

• To access all the resources presented today, please go to:

• https://www.cheerequity.org/iycfe-resources.html